1. bacteremia

What is a CRBSI?

A central line-associated bloodstream infection (CRBSI)

What are some risk factors for CRBSI

Underlying disease Method of insertion Site of catheter and duration Purpose of catheter

How do we diagnose CRBSI?

An organism present on catheter tip and 1 peripheral blood sample OR Organism on catheter hub/lumen blood and peripheral blood sample

True or false, do we get a blood culture before antibiotics?

True

What are some of the common CRBSI bacteria?

CoNS, S. Aureus, Gram negative bacilli

What are some of the CoNS bacteria?

S. Epidermis, S. Saprophyticus, S. Hominis, S. haemolyticus

What is the empiric treatment of CRBSI?

Vancomycin

When do we add gram negative coverage to empiric treatment of CRBSI?

Critically ill, recent MDR, neutropenic, femoral cath., hemodialysis

What do we add on for gram negative coverage?

Cefepime, Pip/taz, Meropenem, Imipenem/ cilastatin

When do we consider adding antifungal coverage for empiric CRBSI?

Prolonged broad spectrum recently, TPN, Femoral cath., hematologic malignancy/ transplant recipients

What do we add for antifungal coverage?

Micafungin

When do we consider catheter removal?

Sepsis/shock, Suppurative thrombophlebitis, endocarditis, positive cultures >72 hours after therapy starts, and certain pathogens

What certain pathogens warrant catheter removal?

Fungi, S. Aureus, mycobacteria, Pseudomonas

When do we replace a long term catheter after removal?

Once bacteremia is cleared

When can we consider catheter salvage?

Limited access site/ need long term access, low virulence pathogen, stable patient, no signs of exit site or tunneled infection

What are some low virulence pathogens?

CoNS

How do we treat infections if we are doing catheter salvage?

Antibiotic lock therapy for IV line + Systemic antibiotics

True or false, is antibiotic lock therapy a higher concentration than peak blood concentrations?

True

What is day 1 for systemic antibiotics in CRBSI?

The first day of a negative culture

What is an uncomplicated CRBSI?

Negative blood culture after catheter removal and no evidence of other infection

How long do we treat uncomplicated CRBSI?

7-14 days

How do we define a complicated CRBSI?

positive blood culture >72 hours after catheter removal, and evidence of endocarditis, osteomyelitis, suppurative thrombophlebitis

How long do we treat complicated CRBSI?

4-6 weeks

How often do we dose post-dialysis drugs?

three times a week

What are the post-dialysis drugs?

Vancomycin, aminoglycosides, cefazolin, ceftazidime, cefepime, and meropenem (not all inclusive)

What is a big concern we have with S. Aureus bacteremia?

Endocarditis since they like to stick to things and can cause tissue damage as well as metastasize through the body

What can S. Aureus cause since it sticks to surfaces?

Biofilms

True or false, S. Aureus is a contaminant?

False

What are the unlikely pathogens in bacteremia?

Corynebacterium, bacillus spp., and C. Acnes

What are the uncertain pathogens for bacteremia?

CoNS

Why are CoNS uncertain in positive blood cultures?

May be contaminants, consider patient risk factors like devices, as well as the #positive/ #cultires

What are the likely pathogens in bacteremia

S. Aureus, Pseudomonas, enterobacterales, C. Acnes, and S. Pneumoniae

What are some of the likely contaminants?

Corynebacterium, bacillus, C. Acnes CoNS, and Viridans strep

What are some examples of Viridans strep.?

S. Mitis, oralis, mutans, saguinis, and salivarius

When do we rule out contaminants for bacteremia

If they have an indwelling catheter, devices/ prosthetics, and immunocompromising conditions

True or False, do we always treat S. Aureus as bacteremia?

True

What is the empiric treatment for S. Aureus bacteremia?

Vancomycin

What is defined as uncomplicated bacteremia for S. Aureus?

negative culture 2-4 days later, afebrile in 72 hours or less, no endocarditis, prosthetic material, or metastatic infection

How long do we treat uncomplicated S. Aureus?

2 weeks from negative culture

How long do we treat complicated S. Aureus bacteremia?

4-6 weeks from negative culture

How do we define complicated S. Aureus?

Does not meet criteria for uncomplicated

What are the treatment options for MSSA?

Nafcillin/oxacillin or cefazolin

What is preferred for MSSA bacteremia?

Cefazolin

What is CIE?

Cefazolin inoculum effect

How do we define CIE

The high efficacy of cefazolin is decreased when there are large numbers of organisms present

What can CIE cause?

Treatment failure and poor outcomes

What do we use to treat MRSA bacteremia?

Vancomycin or daptomycin

What is the Daptomycin dosing for MRSA bacteremia?

8mg/kg/day

What do we consider treatment failure?

Still a positive culture beyond 7 days of treatment

What do we do if we have treatment failure?

Consider alternatives

What are the vancomycin alternatives for MRSA?

Daptomycin, Linezolid, ceftaroline, and combo. therapy

What is involved in combo. therapy for treatment failure MRSA?

Dapto/vanco + Beta lactam

What are some common examples of gram negative bacteremia?

E. Coli, Klebsiella pneumo, Pseudomonas, Enterobacter spp, proteus mirabilis, B. Fragilis

True or false, we can use aminoglycoside mono therapy in gram negative bacteremia?

False

What are some good IV to PO drugs for gram negative bacteremia?

Fluoroquinolones and Bactrim

What do we do if our gram negative coverage agents all have >10% resistance?

Add two agents

What is the duration of gram negative bacteremia treatment?

7-10 days

When can we do 7-10 days instead of 14 for gram negative bacteremia?

source control, hemodynamically stable and afebrile for 48 hours by day 7